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Form Approved.OMB No.2050-DO39 Please print or type. UNIFORM liAZARifOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number J J K WASTE MANIFEST �,Genr rdlDfS��f�e aR Mall}g9 AtldIB55. Generator's Site Address(if different than mailing address) .JUDY L- i=RERICHS PC)BOX-A57 6315 4'e AOICO L�ilf. ;A J G�11 TRACY.CA 05304 Generators Phone: r13-442-456 i 5.Transporter 1 Company Name U.S.EPAID Number IMEWCAN VALLEY WASTE OIL, INC. (--AR000272302 U.S.EPA ID Number 7.Transputer 2 Company Name CLEAN EARTH VMOD01 1 W24 8.Designated Facility Name and Site Address U.S.EPA ID Number�:HtiNl![:HI_►ttGl�hiMi iviv SVi:S T?(Df)4884+4700 405 POV14EL1-STREET .t�A1 i il) TX —6623 Facility's Phone: 9a. 3b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,M Number, 10.Containers 11.Total 12..Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. U00 i =rG 1.€f RU Utii26B WASTE PETROLELIM DISTILLATES N.O.S 3. P011 I "� 0 GA501 INE di ESE! Oi TTS ?t 1 H z 2. w m to 3. 4. 14,Special Handling Instructions.and:Aftd'dtoro Information PROFILE#-240000S4TiP00 GAS,WATER ERC 1121+ EMERGENCY GCW'ACT'MARTY 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabeiedlpiacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulagons.if export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgmert of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. /; Signature Month 4ay Year Genn}erar/to�r•slOfferor's/}PrintedlTyped Namm/p... (f/ r' � 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: [ zpate leaving U.S.: Transporter signature(for exports only): 17.Transporter Acknowledgment of Receipt of Materials QTransporterl PrintediTyped Name Signature Day Year aTransporter 2 Pfintedi`lr ,Name Signature I Month Day Year `I 1B.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Res€due ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: [fir ISc.Signature of Alternate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes ji.e.,nodes for hazardous waste treatment,disposal,and recycling systems) U-1 1 2. 3. § 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 1 Ba Prinled(fyped Name Signature- Month Day. Year EPA Form B700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR